Lessons Learned From the Balancing Incentive Program RTI International Joshua M. Wiener, PhD Sara Karon, PhD Molly Knowles, MPP Brieanne Lyda-McDonald, MS Trini Thach, BS NASHP Diane Justice, MA Scott Holladay, MPA John Tranfaglia, BA NASDDDS Mary Sowers, BA RTI International is a registered trademark and a trade name of Research Triangle Institute. www.rti.org
Acknowledgements This research was supported by the Office of the Assistant Secretary for Planning and Evaluation/U.S. Department of Health and Human Services under Contract #HHSP23320100021WI. We gratefully acknowledge the contributions of Pam Doty, PhD, and Jhamirah Howard, MPH, our ASPE Contracting Officer Representatives, for their contributions to this project. We also appreciate the thoughtful review and input from key CMS staff. The views expressed in this presentation are those of the authors and do not necessarily represent the views of ASPE or RTI International. 2
Balancing Incentive Program Authorized under the Affordable Care Act Designed to increase use of HCBS and improve the infrastructure States were eligible if less then 50% of their LTSS spending was for HCBS, in FFY 2009 States received enhanced FMAP (2% or 5%, depending on baseline spending) States begin participation between April 1, 2012, and October 1, 2014 The program ended September 30, 2015 CMS has granted some states extensions of time to achieve goals or to spend FMAP received 3
Balancing Incentive Program Goals Increase share of LTSS expenditures used for HCBS For states with <25% for HCBS at baseline (2009), increase to > 25% For states with HCBS < 50%, but greater than 25%, increase to > 50% Improve infrastructure to ensure an equitable, userfriendly, consistent process Create a No Wrong Door/Single Entry Point system Design and implement a Core Standardized Assessment Ensure Conflict Free Case Management 4
Focus of the Balancing Incentive Program Program included all populations receiving Medicaid LTSS Measures of expenditures were calculated across all populations Infrastructure changes were intended to create a more equitable process across populations (especially core standardized assessment) Approaches could have differential impact on population groups States had great flexibility in how they implemented the required goals 5
Presentation Structure Preliminary outcome findings Methods used to achieve goals Impacts of changes on people with intellectual or developmental disabilities 6
Methods Document review Quarterly progress reports States Balancing Incentive Program applications and work plans Summary briefs (Mission Analytics) Annual report on LTSS Expenditures (Truven Analytics) Other documents 7
Methods (cont.) Includes 18 of 21 participating states Nebraska participated for less than one year Two other states ended participation early; some data exist but are not included in the analyses presented here Outcome evaluation, from implementation through September 30, 2014 Will be updated through September 20, 2015, when final expenditure data are available (anticipated Spring 2017) Process evaluation, from implementation through September 30, 2015 8
9 Preliminary Outcome Evaluation Results
Outcomes Evaluated: Preliminary Results Percentage of LTSS expenditures for home and community-based services (through September 30, 2014) Infrastructure changes No wrong door/single entry point Conflict-free case management Core standardized assessment 10
Medicaid Home and Community-Based Spending as Percentage of LTSS Among Balancing Incentive Program States: FY 2014 2009 2014 Total HCBS/Total LTSS 40.7% 52.1% Average Across Participating States 39.4% 50.2% 11
Medicaid Home and Community-Based Spending as Percentage of LTSS By FY 2014, in 9 of the 18 states, more than 50 percent of LTSS was for HCBS On average, Balancing Incentive Program states had greater percentage point increase in HCBS as a percentage of LTSS than in 5-year period before program Balancing Incentive Program States had greater increase in HCBS spending as a share of total LTSS expenditures than states that were eligible but did not participate 12
Medicaid HCBS as Proportion of Total LTSS Spending by Population Group, 2009 and 2014 Balancing Incentive Program States Eligible, but Not Participating States Older People and Younger People with Physical Disabilities 2009 2014 2009 Older People with I/DD Average Across States 26.6% 30.8% 64.0% 70.9% 26.9% 28.0% 68.8% 80.5% 13
Achievement of Infrastructure Requirements by States Participating in the Balancing Incentive Program, September 30, 2015 Total States with All Infrastructure Criteria Achieved NWD/ SEP CSA Tools and Processes CFCM All Infrastructure Requirements Met Infrastructure and Expenditure Requirements Met 14 15 17 14 9 Numbers shown are of 18 total states participating. 14
Preliminary Conclusions on Outcomes States increased the share of LTSS spending on HCBS, as of FY 2014 States that participated in the Balancing Incentive Program had a greater increase in HCBS spending than did other States Increase in the share of LTSS expenditures spent on HCBS varied by population Most states achieved the required infrastructure changes 15
16 Process Evaluation Findings, as of September 30, 2015
No Wrong Door/Single Entry Point System Key Components Standardized informational materials for consumers Training staff on eligibility determination and enrollment processes Implementing a clear and consistent process to guide people through assessment and eligibility determination Establish a NWD/SEP website Establish a NWD/SEP 1-800 telephone number for consumers 17
Achievement of NWD/SEP System Across all states, an average of 91 percent of required tasks were completed All but three states reported delays in planned completion Implementing the process was the most readily achievable task Number of states completed Average percent completed Number of states with delays Develop Materials Train Staff Implement Process Establish Website Establish 1-800 Number All Tasks 15 15 16 14 15 14 92 89 92 91 92 91 11 10 8 9 5 15 18
Core Standardized Assessment All states completed development of a Level I Screen Assessment to determine financial and functional status, and likely eligibility for services All but one state finished incorporating domains and topics into assessments to address all components of the CMS Core Dataset Most states trained staff at NWD/SEP in use of the assessment Develop Level I Screen Incorporate Domains and Topics Train Staff All Tasks Number of states completed 18 17 16 15 Average percent completed 100 96 93 96 Number of states with delays 9 9 10 13 19
Conflict-Free Case Management States must establish protocol for removing any conflict of interest that may exist when the same organization both develops the care plan and provides the service States must continually evaluate structures to ensure regulatory compliance Similar requirements exist for 1915(k) and State Plan HCBS All states met this requirement Five states reported delays 20
Optional State Goals Some optional goals stand alone Expand mental health services (6 states) Improve services for people with intellectual or developmental disabilities (2 states) Improve quality measurement (4 states) Other optional goals support progress toward the required goals, especially the goal of increasing the share of LTSS spent on HCBS Expand waiver slots/eliminate waiver waiting lists (10 states) Expand state plan HCBS to serve more individuals, new populations (5 states) Increase rates for HCBS (6 states) Support transition from institution to the community (5 states) 21
States Used a Variety of Medicaid Coverage and Eligibility Options Money Follows the Person 1915(c) Waivers Personal Care Option 1915(i) State Plan Option 1915(k) Health Homes 1115 R&D Waiver TOTAL 18 18 10 5 4 10 7 Existing 11 5 9 1 0 3 5 Expanded 7 13 1 1 0 2 1 New 0 1 0 3 4 5 1 22
Interaction With Money Follows the Person Balancing Incentive Program funds were used to help support MFP goals Educate nursing facility staff and residents about community-based supports available for transitioning to the community (2 states) Expand the MFP program to other populations (1 state) Use MFP funds to further the goals of the Balancing Incentive Program Support initial costs of implementing the three structural changes (7 states) Develop new assessment tools and train staff in their use (2 states) Use established stakeholder groups to support system change activities 23
Interaction of Balancing Incentive Program With Other Medicaid Programs Waiver slots could be increased either through 1915(c) funds or using Balancing Incentive Program funds Balancing Incentive Programs funds were used by some states to plan and implement new 1915(i) and 1915(k) state plan options Balancing Incentive Program funds were used in one state to support development of health homes and in another to increase Medicaid payment for providers participating in health homes 24
Interaction of Balancing Incentive Program With Other Medicaid Programs (cont d) Balancing Incentive Program funds could be used to enhance states ADRC; or ADRC resources could support state development of the NWD/SEP Other support for the Balancing Incentive Program came from CMS imitative of Enhanced Funding for Eligibility Enrollment Systems, and State Innovation Model Demonstrations 25
Stakeholder Involvement Formal advisory boards were convened in 15 states Advisory boards included providers (9), policymaker (8), and consumers/advocates (8) Meetings with stakeholder groups were held in 9 states Primarily involved consumers/advocates (8) and providers (8) Some states (4) also met separately with policymakers Use of stakeholders to pilot test proposed actions or assessments (6 states), primarily with consumers/advocate (5 states) or providers (3 states) 26
Focus on Populations States could identify specific populations to focus efforts on, as part of their application and initial work plan People Age 65+ Physical Disabilities Intellectual/ Developmental Disabilities People with Serious Mental Illness or Substance Use Disorder Other Disabilities or Chronic Conditions Baseline Plans 15 15 16 15 6 Actions Taken Increase access Increase payment 8 9 13 7 5 5 5 4 2 5 Other 5 3 3 5 2 27
Conclusions Despite delays, most states were able to accomplish the required infrastructure changes. States leveraged resources and opportunities from a variety of Medicaid programs to help achieve the required changes. States may think globally about changes to the Medicaid system, and use various programs to achieve these goals 28
Conclusions (cont d) Although infrastructure changes are designed to benefit all populations, other actions may not have benefitted all populations equally. Future efforts may seek to improve HCBS opportunities for populations that have higher rates of institutionalization. 29
Contact Information Joshua M. Wiener, PhD Distinguished Fellow RTI International jwiener@rti.org 202-728-2094 Sara Karon, PhD Senior Researcher Aging, Disability and Long-Term Care Program RTI International skaron@rti.org 919-248-8517 30
September 1, 2016
State systems support 1.1 million individuals with disabilities and their families annually In Federal Fiscal Year (FY) 2014, federal and state governments spent approximately $41.8 billion on Medicaid LTSS for individuals with I/DD* In FY 2014, HCBS represented three-fourths of LTSS dollars targeted to people with developmental disabilities (75 percent) Eiken, S., Sredl, K., Burwell, B., & Saucier, P. (2016, April). Medicaid expenditures for long-term services and supports (LTSS) in FY 2014: Managed LTSS reached 15 percent of LTSS spending. Truven Health Analytics. Retrieved from https://www.medicaid.gov/medicaid-chip-program-information/by-topics/long-term-services-andsupports/downloads/ltss-expenditures-2014.pdf.
The Balancing Incentive Program provided an opportunity for states to ensure continued progress toward the balance that had been achieved in the I/DD systems. I/DD systems were early adopters of the 1915(c) waiver authority in the late 1980s and early 1990s, contributing to the tipping of the balance toward HCBS. In some states, however, institutional reliance remains high.
1967 194,650 1926 55,466 2014 21,908 Larson, S.A., Hallas-Muchow, L., Aiken, F., Taylor, B., Pettingell, S., Hewitt, A., Sowers, M., & Fay, M.L. (2016). In- Home and Residential Long-Term Supports and Services for Persons with Intellectual or Developmental Disabilities: Status and trends through 2013. Minneapolis: University of Minnesota, Research and Training Center on Community Living, Institute on Community Integration.
States require infrastructure improvements, like those required by BIP, to ensure quality and choice within HCBS, and to spur the continued development of meaningful community-based, person-centered services.
18 of the 38 states eligible based on 2009 spending levels participated in the Balancing Incentive Program Of those, 16 targeted children and adults with I/DD for Balancing Incentive Program rebalancing efforts These efforts were largely aimed at furthering or maintaining progress on community based LTSS for individuals with I/DD (the share of spending on HCBS was already at 60.7% on average across participating states 2 ) 1. Wiener, J., Karon, S., McGinn-Shapiro, M., Lyda-McDonald, B., Thach, T., Justice, D., et al. (2015, August). Descriptive overview and summary of Balancing Incentive Program participating states at baseline. RTI International. Retrieved from https://aspe.hhs.gov/execsum/descriptive-overview-and-summary-balancing-incentive-program-participating-statesbaseline
Improve data and information technology Improve systems for conflict free case management Improve opportunities to gain key information to inform person-centered planning efforts Spur system transformation to further goals of community integration 7
CMS 2009 data showed New York HCBS expenditures at 46.7% (59.5% for I/DD) New York was eligible for 2% enhanced FMAP Approved effective July 1, 2013 Received CMS award of $598,665,500 OPWDD received BIP funding that totaled over $356 million 8
OPWDD utilized funds for a variety of activities aimed at spurring greater opportunity for community based services: Housing projects worked to build partnerships with housing authorities in effort to increase availability of housing options and the number of housing units available to individuals being transitioned from institutional settings (no dollars used for housing directly) Employment efforts - to increase the number of individuals engaged in competitive employment, supporting the transition of individuals from traditional day habilitation and sheltered workshops to integrated businesses. Self-direction efforts - to support an increase in the number of individuals who choose to self-direct their services and supports
Deinstitutionalization activities - to support the successful transition of individuals residing in Developmental Centers and campus-based and noncampus based Intermediate Care Facilities (ICFs) to home and community based settings Initiatives supporting the transition to managed care - to meet the organizational and structural challenges of providing new or expanded offerings of non-institutionally-based long-term services and supports during this transition, while maintaining high standards to deliver (and increasingly measure quality services) and organizational governance. Expand community capacity - NY START - a community-based program that provides crisis prevention and response services to individuals with intellectual/developmental disabilities and behavioral health needs, as well as their families and those who provide support within the community.
CMS 2009 data showed Ohio HCBS expenditures at 32.5% Ohio was eligible for 2% enhanced FMAP Approved effective July 1, 2013 Received CMS award of $169,076,032 Department of Developmental Disabilities received an estimated $70 million.
Ohio engaged in a collaborative approach across the entire LTSS system. Utilized resources to improve IT resources to support NWD Develop and improve assessment tools and instruments Build strategies to mitigate conflict within the case management systems within the state
State staff were asked to identify the biggest benefit to their state from BIP: Investments made (1) to transition away from sheltered workshops to a different employment structure -- an integrated and community based business model; (2) to build robust care coordination models that are IT supported; and, (3) perhaps most significant, was the increasing attention paid to person-centeredness and culture change across the system. Focusing our energies on community transitions and the ability to utilize BIP dollars to fund innovative projects. States also indicated a commitment to maintain those efforts that promise to the greatest degree possible.
Systems supporting I/DD broadly benefited from the Balancing Incentive Program. Some states had very specific and targeted efforts aimed at the unique infrastructure and provider capacity within the I/DD systems Other states benefited from broad-based LTSS improvements within their states underwritten by BIP. BIP provided an opportunity for state agencies to partner and build organizational relationships that will continue to benefit individuals receiving LTSS.